Commission for Environmental Cooperation
and the Environment in North America
Children’s Health
A First Report on Available Indicators and Measures
ii
DISCLAIMER
This report was prepared by the CEC Secretariat in coordination with the Steering Group for the Development
of Indicators of Children’s Health and the Environment in North America, which is composed of officials of
the Governments of Canada, Mexico and the United States, and representatives of the CEC, the International
Joint Commission’s Health Professionals Task Force (IJC HPTF), the Pan American Health Organization
(PAHO), and the World Health Organization (WHO). This North American report is based primarily on
information contained in separate “country reports” prepared by Canada, Mexico and the United States
(available at
Not all information and statements in the report necessarily reflect the views of the Governments of Canada,
Mexico and/or the United States, or the CEC Secretariat, IJC, PAHO and/or WHO, in part because the report
is a compilation of information provided separately by the three different countries.
Commission for Environmental Cooperation
393, rue St-Jacques Ouest, Bureau 200
Montréal (Québec) Canada H2Y 1N9
t (514) 350-4300 f (514) 350-4314
/ www.cec.org
Printed in Canada on paper containing 100% post-consumer waste fiber.
© Commission for Environmental Cooperation, 2006
Legal Deposit-Bibliothèque nationale du Québec, 2006
Legal Deposit-Bibliothèque nationale du Canada, 2006
ISBN: 2-923358-32-5
All images used with permission
Prepared by:
Secretariat—Commission for Environmental Cooperation
In collaboration with:
International Joint Commission—Health Professionals Task Force

_______ _
7
1.6 The First North American Report
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9
2.0 An Introduction to the Participating Countries
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11
2.1 Population Data and Birth Rates
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12
2.2 Child Mortality and Morbidity
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12
2.3 Immunization Rates as an Indicator of Availability of Public Health Services
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13
2.4 Socioeconomic Determinants of Health
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13
3.0 Asthma and Respiratory Disease
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15
3.1 Outdoor Air Pollution
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16
3.1.1 Canada
3.1.2 Mexico
3.1.3 United States
3.1.4 Opportunities for Strengthening Indicators of Outdoor

4.1.4 Opportunities for Strengthening Indicators
of Children’s Exposure to Lead in North America
4.2 Lead in the Home
_______ _
51
4.2.1 Canada
4.2.2 Mexico
4.2.3 United States
4.2.4 Opportunities for Strengthening the Indicator on Children’s
Exposure to Lead in the Home, in North America
4.3 Industrial Releases of Lead
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55
4.3.1 Canada
4.3.2 Mexico
4.3.3 United States
4.3.4 Opportunities for Strengthening Indicators of Lead
from Industrial Activities in North America
4.4 Industrial Releases of Selected Chemicals
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59
4.4.1 Canada
4.4.2 Mexico
4.4.3 United States
4.4.4 Opportunities for Strengthening PRTR-based Indicators in North America
4.5 Pesticides
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65
4.5.1 Canada
4.5.2 Mexico

6.0 Lessons Learned and Actions Needed
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93
List of Figures and Charts
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96
List of Abbreviations
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98
Glossary
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99
References
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104
Appendix 1: Council Resolution 02-06
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107
Appendix 2: Overview of Recommended Indicators from the CEC Council
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109
Appendix 3: Council Resolution 03-10
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111
Appendix 4: Members of the Steering Group for the Development

of Indicators of Children’s Health and theEnvironment in North America
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112
Appendix 5: Expert Review Panel

Although the data are thin, it appears that while lead levels in children’s blood are on the decline
in many parts of the continent, particular socio-economic groups remain at higher risk. On the
positive side, available data indicate that pesticides residues in foods in Canada and the US, and
acute poisonings in Mexico, are on the decline. With respect to water quality and waterborne
disease, Mexico continues to face the largest challenges regarding access to safe drinking water
and sanitation services, although progress is being made which no doubt is contributing to the
decline in diarrheal diseases among Mexican children.
Children deserve not only our love and affection, they deserve special diligence on our part
to ensure that they have the chance to thrive in a safe and nurturing world. On an individual
level, we can do our part to care for our children and keep them out of harm’s way. But the ever-
increasing evidence of the overt and subtle effects that a degraded environment can have on
children’s health means that we also must act collectively. Acting alone, none of us can stem
the problems of urban air pollution, toxic contamination, or poor water quality. But working as
neighbors, communities, countries, and globally, we can make a difference.
This report marks the beginning of an important new direction for North America. It is
the culmination of many months of work by dedicated people from across the continent
and globally, representing the governments of Canada, Mexico and the United States and
the partner institutions, namely CEC, IJC, PAHO and WHO. It refl ects the expertise of a
trinational review panel and the ideas of members of the public who provided their input. It
is also a refl ection of the efforts of the countless many who have worked tirelessly over recent
decades to promote environmental and child health protection. With this depth of support and
momentum, this report is a reaffi rmation of the importance that North Americans place on the
health and well-being of their children. It is also an acknowledgement of the value of information
in guiding our decision-making and shaping our priorities.
CHILDREN’S HEALTH AND THE ENVIRONMENT IN NORTH AMERICA
vii
Children's Health and the Environment in North America
viii
In this report, we look at indicators in three thematic areas: (1) asthma and respiratory disease;
(2) lead and other chemicals, including pesticides; and (3) waterborne diseases. These areas refl ect

in some cases, writing the bulk of, the country reports. They were assisted not only by their colleagues in the Steering
Group but also by staff in various governmental departments who reviewed and commented on drafts of the report.
The following governmental offi cials deserve particular recognition for their valuable contributions:
For the Government of Canada (Environment Canada and Health Canada), Annie Bérubé, former country lead,
played a leading role in compiling the Canadian country report and, along with Nicki Sims-Jones and Vincent Mercier
(current country lead), contributed greatly to bringing both the Canadian report and this North American volume to
fruition. Others who contributed from Canada include Julie Charbonneau, Andrea Ecclestone, Susan Ecclestone, Kerri
Henry, Amber McCool, Anthony Myres, Daniel Panko, Risa Smith, and Emma Wong. For the Government of Mexico
(Ministry of Health), Antonio Barraza, former country lead, was the primary author of the Mexican country report and
thus a main contributor to this volume. Matiana Ramírez, the current country lead, played a key role by bringing the
Mexican country report as well as the Mexican sections of this report to completion. Other contributors from Mexico
include Rocio Alatore and Martha Plascencia. For the Government of the United States (Environmental Protection
Agency), Ann Carroll (current country lead), Tracey Woodruff (technical expert), Daniel Axelrad (technical expert)
and Edward Chu (former country lead) were the authors of the US country report and contributed greatly to this North
American compilation. Catherine Allen (former country lead) and Evonne Marzouk (former country lead) played key
roles in the Steering Group during the early stages of the report’s development. Brad Hurley provided technical support
and served as a consultant for the US country report. Martha Berger served as observer.
Offi cials from each of the partner institutions also contributed their time, vision and expertise to this undertaking.
In addition to this in-kind support, the IJC and PAHO also provided fi nancial contributions to the CEC for the
ix
Children's Health and the Environment in North America
On behalf of all of the partners in this indicators initiative—the three North American countries
and our four respective institutions—we hope that you will fi nd this report useful, and that you
will join us in our common pursuit of a safe and sustainable environment for our children and
for future generations.
William V. Kennedy
E
XECUTIVE DIRECTOR
Commission
for Environmental

(WHO)
implementation of the project. WHO staff provided a vital link to the Global Initiative on Children’s Environmental
Health Indicators, fostering the exchange of ideas and approaches with other regions of the world. Special thanks go
to the following individuals from the partner institutions who contributed through their involvement in the Steering
Group: For the IJC (Health Professionals Task Force): Irena Buka, James Houston, Pierre Gosselin, and Peter Orris; for
PAHO: Luiz Augusto (‘Guto’) Galvão, Pierre Gosselin, Samuel Henao, and Alfonzo Ruiz; and for WHO: Fiona Gore
and Eva Rehfuess. Pierre Gosselin is specially noted for his role in advocating for the project in its early days.
It would be impossible to overstate the important contribution of the panel of experts who generously gave of their time
and expertise to the development and improvement of the report. The nine-person panel, composed of three experts
nominated by each of the three countries, met in Ottawa, Canada, in March 2004 to provide guidance and expertise based
on their review of a fi rst draft of the report. The panel conducted a second in-depth written review of a subsequent draft
in December 2004/January 2005. The experts also offered information and input on an ad hoc basis at various points
during the project as the Steering Group worked to improve the report. Heartfelt thanks go to: Pumolo Roddy, Teresa To
and Don Wigle from Canada; Enrique Cifuentes García, Cristina Cortinas de Nava, and Alvaro Román Osornio Vargas
from Mexico, and Patricia Butterfi eld, Daniel Goldstein, and Melanie Marty from the United States.
Numerous people from the CEC Secretariat played a role in bringing this report to fruition. Erica Phipps, former
program manager for the CEC’s work on children’s health and the environment and now a consultant to the CEC,
has coordinated the work of the Steering Group since its inception and was instrumental in getting the project off the
ground. Victor Shantora, the former head of the CEC’s pollutants and health program, provided unfailing support and
guidance. Keith Chanon, current program manager, helped see the report through to its publication. Marilou Nichols,
program assistant, provided effi cient support for the project. The CEC’s communications staff has played a vital role,
especially Jeffrey Stoub, who tirelessly managed the editing and translation of numerous drafts of the report and the
publication of the fi nal version.
Very special thanks are due to Bruce Dudley of the Delphi Group who, under contract with the CEC, undertook the
tremendous job of compiling this report. Bruce contributed many long hours to the writing, research and coordination
required to bring the report to completion. He was assisted for most of the project by Samantha Baulch, whose careful
attention to detail and unfailing good nature contributed greatly to its success. Erin Down provided assistance as the
report neared completion.
It is our hope that the excellent collaboration and good will that led to the creation of this fi rst report will carry through
into future efforts to build on the indicators presented herein and, most importantly, to safeguard the health of our

Commission Health Professionals Task Force (IJC HPTF), the World Health Organization (WHO), the Pan
American Health Organization (PAHO), and together with the three member countries, Canada, Mexico
and the United States, embarked upon the development of the fi rst regional report on indicators of
children’s health and the environment. The Organization for Economic Cooperation and Development
(OECD) participated in this initiative as an observer.
This CEC-led effort also forms part of the Global Initiative on Children’s Environmental Health
Indicators (CEHI), which was endorsed at the World Summit on Sustainable Development (WSSD)
and is led by WHO (< with support from the US
Environmental Protection Agency (EPA). As such, this report represents a signifi cant regional
learning opportunity that may help to inform similar projects in other parts of the world.
The indicators in this report refl ect the CEC priorities, as defi ned by the Council. The CEC
priority areas for children’s health and the environment include: asthma and respiratory
disease, lead and other toxic substances, and waterborne diseases. The countries committed
to presenting information on an initial set of twelve indicators (see A
PPENDIX 2). These were
selected based on the availability of data to present information on them, and on their relevance
to the priority issues. From this initial set of twelve indicators, the Steering Group for this report
elected to add an additional pollutant release and transfer register (PRTR) indicator on lead.
Also, for reporting purposes, the Steering Group elected to merge two indicators on drinking
water into one, and two indicators on waterborne diseases into one. Essentially, there are thirteen
indicators, organized under eleven thematic headings, for this report. Recognizing the value of
building on existing data and improving over time, a fl exible approach was adopted to enable
countries to report related information if they were not able to present information on any of
these indicators. As a result, not all indicators are comparable across the three countries.
1
The CEC Council is composed of the top-ranking environmental officials from the three North American countries,
Canada, Mexico and the United States. Council Resolutions, including CR02-06, can be found at <.
org/who_we_are/council/members/>.
xiii
Children's Health and the Environment in North America

xiv
The Indicators
The report presents thirteen indicators that fall within three priority areas that have been defi ned by the
CEC Council for the countries’ cooperative work on children’s health and the environment, namely: asthma
and respiratory disease, lead and other chemicals, and waterborne diseases. These thirteen indicators,
which are organized under eleven thematic headings, are summarized in C
HART I-1 below.
CHART 1: List of Indicators for Children’s Health and the Environment in North America
Asthma and Respiratory Disease
I
____________________________
I
_______________________________________________________________
_
_________
I
Issue Area Current Indicator
I
____________________________
I
__________________________________________________________________
_
______
I
Outdoor Air Pollution Percentage of children living in areas where air pollution levels
exceed relevant air quality standards
I
____________________________
I
__________________________________________________________________

I
____________________________
I
_______________________________________________________________________
_
_
I
Lead Body Burden Blood lead levels in children
I
____________________________
I
______________________________________________________________________
_
__
I
Lead in the Home Children living in homes with a potential source of lead
I
____________________________
I
_______________________________________________________________________
_
_
I
Industrial Releases of Lead Pollutant release and transfer register (PRTR) data on industrial
releases of lead
I
____________________________
I
_______________________________________________________________________
_

I
_______________________________________________________________________
_
_
I
Drinking Water (a) Percentage of children (households) without access to treated water
(b) Percentage of children living in areas served by public
water systems in violation of local standards
I
____________________________
I
______________________________________________________________________
_
__
I
Sanitation Percentages of children (households) that are not served with sanitary sewers
I
____________________________
I
______________________________________________________________________
_
__
I
Waterborne Diseases (a) Morbidity: number of cases of childhood illnesses attributed to
waterborne diseases (Canada, Mexico, United States)
(b) Mortality: number of child deaths attributed to waterborne diseases (Mexico)
I
____________________________
I
______________________________________________________________________

southern Ontario experienced the highest numbers of days on which ground-level ozone and
PM
2.5
levels exceeded the Canadian standards.
In Mexico, population-based exceedance data are not available; however, air quality data for
ground-level ozone and PM
10
for several major urban air monitoring zones are presented as a
proxy indicator. The observations from this data indicate that air quality standards for ground-
level ozone and particulate matter (PM
10
) were exceeded in key metropolitan areas, most notably
for ground-level ozone in Mexico City and for particulate matter (PM
10
) in Guadalajara, Mexico
City, Monterrey, Toluca and Ciudad Juárez.
The United States presents data on the percentage of children living in counties in which air
quality standards were exceeded. The data indicate that a high percentage of children are living
in counties where levels of ground-level ozone exceed standards. A smaller, but still signifi cant,
percentage of children are living in counties where PM
2.5
levels exceed standards; however, this has
been decreasing.
Indicator No. 2—Indoor Air Pollution
I
_________________________________________________________________________________________________
_
___
I
This indicator measures children’s potential exposure to indoor air pollution, with a focus on environmental

___
I
This indicator tracks asthma in children, a disease of the lungs that affects millions of children in North
America. Asthma is a major cause of child hospitalization and is the most common chronic disease of
childhood in North America.
Canada reports on the prevalence of physician-diagnosed asthma among children. These data
indicate that asthma prevalence among children has continued to increase in most age groups,
between 1994 and 1999. For example, the percent of boys aged eight to 11 who were diagnosed
with asthma increased from approximately 16 percent in 1994/1995 to approximately 20 percent
in 1998/1999. For girls of the same age range, the increase was from approximately 11 percent to
approximately 15 percent.
Mexico presents data on the incidence of asthma among children. These data show an increase
in nearly all age groups over the period 1998 to 2002. For example, in 2002, 35 children out
of every 10,000 aged fi ve to 14 years had asthma, up from 28 per 10,000 in 1998. Mexico also
presents national incidence of acute respiratory infections (ARI) among children. The number
of new cases of ARI was stable or up slightly over the period 1998 to 2002, with the highest
prevalence among children under one year of age.
The United States presents survey data on asthma prevalence for all age groups between 1980 and
2003. Over the period 1980 to 1995, the percentage of children with asthma doubled. In 2003, 13 per-
cent of American children had been diagnosed with asthma at some point in their lives.
xvii
Children's Health and the Environment in North America
INDICATORS RELATED TO LEAD AND OTHER CHEMICALS, INCLUDING PESTICIDES
Indicator No. 4—Blood Lead Levels
I
_________________________________________________________________________________________________
_
___
I
Lead is a major environmental hazard for young children. Exposure to lead can result in neurological

include lead in dust, lead-based paint and lead in plumbing, in Canada and the United States. In Mexico, a
major source of indoor lead is home-based pottery operations using lead-based glaze. Lead-based glazes may
also result in exposure to lead through the use of this pottery in food preparation, serving and storage. This
indicator provides information on children’s potential exposures to sources of lead in the home.
For this indicator, Canada presents information on the percentage of children living in homes
built before 1960. In Canada, homes built before 1960 are more likely to contain paint with high
concentrations of lead. This lead can increase the potential for exposure through lead dust if the
older paint is exposed due to renovations or deterioration (i.e., peeling and fl aking). According
to the data provided, there has been a modest decline in the number of children living in homes
built before 1960. For example, in 1991, 28 percent of children four years and under lived in
housing built prior to 1960. This had declined to 24 percent by 2001.
Mexico is unable to present data on this indicator. Instead, Mexico presents geographic
information on the density of home-based pottery operations in various states. The map shows
that the distribution of pottery facilities is most dense in southern Mexico.
xviii
The United States is unable to present child-specifi c information for this indicator. Instead,
the United States provides data from a nationally representative sample on the percentage of
housing contaminated with lead-based paint, lead-based dust or lead-based soil. This indicator
shows that between 1998 and 2000, 40 percent of homes had some lead-based paint. Twenty-fi ve
percent of the homes had a signifi cant lead-based paint hazard.
Indicator No. 6—Industrial Releases of Lead
I
_________________________________________________________________________________________________
_
___
I
In this section, PRTR data

2
serve as an action indicator and depict trends in industrial releases of lead to the

of facilities reporting over that period increased by 41 percent. The reduction in releases was
realized in part through reductions reported by the primary metals sector (with a decrease of 33
percent) and the chemical manufacturing sector (a decrease of 36 percent).
Mexico did not report this indicator, given that the mandatory PRTR program in Mexico is not
yet operational.
2
Data reported by industrial facilities to the National Pollutant Release Inventory (NPRI) in Canada and the Toxics
Release Inventory (TRI) in the United States on certain chemical substances released to air, water, land or transferred
off-site for further management. Only those data elements (i.e., chemicals and industry sectors) that are comparable
between the Canadian and US systems are included. Comparable data are not yet available under the Mexican PRTR.
xix
Children's Health and the Environment in North America
The US data for the 153 matched chemicals depict an overall reduction of 11 percent, from
1998 to 2002 (from 1.45 million tonnes in 1998 to 1.28 million tonnes in 2002), with a slight
reduction in the number of reporting facilities over the same period. Reductions were reported
by various sectors, including the electric utilities sector (9 percent reduction), the chemical
manufacturing sector (24 percent reduction) and the hazardous waste management/solvent
recovery sector (36 percent reduction). The primary metals sector, reporting the second largest
amount of releases behind electric utilities in 2002, had an increase of 16 percent.
Indicator No. 8—Pesticides
I
_________________________________________________________________________________________________
_
___
I
Children and infants may be more vulnerable to potential health effects from pesticides, due to their unique
susceptibilities (especially the growth and development of body systems) and higher intake as a result
of their dietary habits and immature detoxifi cation systems. While there are numerous ways in which a
child may be exposed to pesticides (e.g., exposure to pesticides used on lawns or in the home, or through
contaminated drinking water), the focus of the present indicator is on pesticide residues in foods.

systems in 1999. It is assumed that this group relies on private water supplies, with the principal
source being groundwater wells. Canada does not report on the second indicator in this section,
the percentage of children served by drinking water systems with violations. Such data are
requested from the municipal systems and collected by the provinces, but are not available in a
consistent form that could be used to generate a national indicator.
Mexico is unable to present child-specifi c data for the percentage of children without access to
treated water, but instead presents the percentage of the general population without access to
potable water. Between 1980 and 2000, the percentage of the population without access to potable
water decreased from approximately 29 to 12. The indicator shows that urban populations have
greater access, with only 5 percent of people without access, while in rural areas 32 percent lack
access as of 2000. Mexico also provides a geographic representation of the lack of piped water as
of 2000. The northern and central states of Mexico were the best served, with between 0 to 20
percent without coverage. Mexico is not able to report on the second indicator, the percentage of
children served by drinking water systems with violations.
The United States does not present data for the percentage of children not served with treated
water. For the second indicator, the United States reports on the percentage of children served by
public water systems that exceed or violate a drinking water standard. Between 1993 and 1999,
the percentage of children living in areas with any health-based violation decreased from 20
percent to 8 percent. The United States also reports on the percentage of children living in areas
with major violations of drinking water monitoring and reporting requirements. From 1993 to
1999, the percentage of children living in areas that had any major violation of water monitoring
and reporting dropped from 22 to approximately 10 percent.
xxi
Children's Health and the Environment in North America
Indicator No. 11—Sanitation
I
_________________________________________________________________________________________________
_
___
I

waterborne diseases (in the case of Mexico).
Canada reports on the number of cases of childhood illness attributed to waterborne diseases by
presenting incidence of giardiasis among different age groups, between 1988 and 2000. Giardiasis,
sometimes called “beaver fever,” is an intestinal parasitic infection characterized by chronic
diarrhea and other symptoms. Giardiasis may be foodborne, but waterborne transmission is
common where unsanitary conditions exist or animal contamination occurs. The data show
xxii
that children aged one to four are more likely to be infected with giardiasis than the rest of the
population and that the number of cases of giardiasis in Canada has been declining since 1992.
Canada has elected not to report on the second indicator, mortality from waterborne diseases,
due to low mortality rates.
Mexico reports on the number of cases of childhood illness attributed to waterborne diseases
by presenting incidence of giardiasis, by age group, for the period 1998 to 2002. The prevalence
of giardiasis for all three age groups has declined since 1998. Children one to four years of age
seem to be the most likely to be infected; however, the number of new cases declined from 21
per 10,000 in 1998 to 16 per 10,000 in 2002. Mexico also reports on the percentage of cases of
cholera among children of various age groups. The age group most affected by cholera is that
of one to four years old, with the percentage of cases ranging from 6 percent to 18 percent of all
cases. Mexico also presents on the second indicator by supplying data on the mortality rates for
diarrhea. The mortality rate, of children under fi ve, for diarrheic diseases declined from 125
per 100,000 in 1990 to 20 per 100,000 in 2002. These data suggest that advances are being made
through actions to improve sewage management and drinking water treatment. In addition,
programs to manage diarrheic diseases are reducing the mortality from this illness.
The United States is unable to provide child-specifi c data for the numbers of childhood illnesses
attributed to waterborne diseases, but is able to present some data on reported waterborne
disease outbreaks for the general population by year and type of water system. The data show
that there were 751 voluntarily reported waterborne disease outbreaks associated with drinking
water systems between 1971 and 2000. The last two years of the monitoring presented a total of
44 outbreaks associated with drinking water, reported by 25 states (18 from private wells, 14 from
non-community systems, and 12 from community systems). The United States has elected not to

More research is also needed to better understand the pathways of children’s exposure to
environmen tal contaminants, including how contaminants cycle in the environment, patterns
of dietary exposure, behavioral activities that put children at increased risk of exposure, and
other such issues. This information is required to support better assessment of risks, for
the development of more accurate indicators, and to improve our ability to target exposure
prevention and reduction efforts.
•
Evidence from biomonitoring programs offers measures of direct exposure (e.g., blood cotinine
indicates exposure to nicotine). This information can be extremely valuable to government
decision makers in order to target policies and program actions to reduce exposures. The use
of biomonitoring as a means of identifying and quantifying exposures should be encouraged
and the resulting information used to create more specifi c indicators. By utilizing the results
biomonitoring efforts, future indicators reports could address chemicals such as mercury that
have known effects on children, as well as chemicals of emerging concern (e.g., brominated
fl ame retardants).
•
Indicators which report prevalence and incidence offer different information useful to understanding
and interpreting the progress of disease and disorders (e.g., asthma). This report refl ects a greater
use of prevalence data; however, to the extent that indicators will continue to evolve, there may be
more focus on indicators of incidence in the future.
•
The thematic areas investigated in this report represent a relatively small sample of all potential
environmental risks to children’s health. Furthermore, the primary focus is on pollutants known to
pose risk to children’s health, but it is well accepted that there are thousands of substances that
have yet to be fully tested for their potential to harm children. Therefore, this effort should not be
thought of as comprehensive, but rather as indicative of the relationship between children’s health
and the environment.
Children’s vulnerability is infl uenced by their limited knowledge of potential risks.
Children must rely upon adults to provide safe conditions for them.
1.0 An Overview of the Children’s Health